Case Reports in Obstetrics and Gynecology最新文献

Hyperreactio luteinalis (HL) is a rare condition that presents as bilateral ovarian enlargement during pregnancy. Typically, it is thought to be caused by increased production of human chorionic gonadotropin (hCG) associated with gestational trophoblastic diseases or multiple pregnancies. The prognosis is relatively good, with many cases resulting in term birth. However, some obstetric complications, such as preeclampsia (PE) and preterm births, have been reported. We present a serious case of HL with subsequent PE that resulted in preterm delivery at 31 weeks of gestation. The soluble fms-like tyrosine kinase-1 (sFlt-1)/placental growth factor (PlGF) ratio was very high at the onset of PE at 24 weeks of gestation, followed by a modest decline, which then increased in proportion to the exacerbation of symptoms. Since HL cases have also been reported to be associated with PE, repeated measurement of the sFlt-1/PlGF ratio proved useful for better pregnancy management.

Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) is a rare congenital anomaly of the genital tract. Since the secretion of sex hormones from the ovaries is preserved, leiomyomas and adenomyomas, which are estrogen-dependent diseases, may develop from the uterine remnant. In contrast, patients with myotonic dystrophy type 1 (DM1), the most common dystrophy in adults, are considered to be at high risk for benign tumors of the female reproductive system, such as uterine leiomyomas and ovarian cysts. A rare case of huge leiomyomas arising from bilateral uterine remnants in a woman with MRKHS with coexisting DM1 is presented. Her chief complaint was abdominal distension. On pelvic magnetic resonance imaging (MRI), two solid pelvic masses showing low signal intensity on T2-weighted imaging were seen. Both the uterine corpus and cervix were unclear, but bilateral ovaries were observed normally on MRI. Two uterine leiomyoma-like masses connected by a band of fibrous tissue were found by laparotomy. As with the MRI findings, the uterine cervix and vagina could not be detected macroscopically. Normal bilateral adnexa and round ligaments were identified. All of her symptoms improved after hysterectomy.

Background: Postpartum hemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality. Uterine artery embolization (UAE) is an effective procedural intervention for controlling PPH. Uterine necrosis (UN) is a rare complication of UAE and its management usually results in hysterectomy. We highlight a case of UAE complicated by UN managed conservatively without hysterectomy.

Case: This is the case of a 30-year-old patient who had a cesarean section delivery and subsequently developed PPH due to uterine atony. The estimated blood loss (EBL) was 2500 ml; despite the use of uterotonic medications and trial of intrauterine balloon tamponade. She successfully underwent a UAE with no immediate complications. The remainder of her postnatal course was uncomplicated, and she was discharged on postoperative day 4. On postoperative day 28, the patient presented with fever, vaginal discharge, and abdominal pain. An abdomino-pelvic computed tomography scan revealed areas of necrosis within the uterus secondary to recent UAE. After minimal clinical improvement, the patient underwent a dilation and curettage with ultrasound guidance. The patient improved clinically and was discharged home to complete a 14-day course of antibiotics.

Conclusion: UAE is an important minimally invasive approach to the management of PPH. UN following UAE can present a clinical challenge to physicians, with the underlying pathophysiology being use of small embolizing particles during UAE and lack of arterial collaterals to embolized areas. A total of 19 cases of UN post-UAE have been described of which most of these cases were managed with a hysterectomy. In this case, an alternative treatment plan was successfully implemented via dilation and curettage under ultrasound guidance for removal of organized necrotic tissue. This was sufficient to improve the patient's symptoms and clinical outcome and saved the patient from the morbidity and mortality risks associated with a hysterectomy.

Introduction: Heterotopic pregnancy (HP) refers to the simultaneous presence of intrauterine pregnancy (IUP) and ectopic pregnancy, which is very rare but potentially life-threatening. The spontaneous incidence of HP in the general population is 1/30,000. With the widespread use of assisted reproductive technology (ART), the incidence rises to 1/1,000. Aims and Methods. This is a prospective case series looking at the cases of heterotopic pregnancies presenting to the early pregnancy unit (EPU) in a tertiary maternity hospital, from November 2015 to November 2016. The clinical presentation, ultrasound findings, and laparoscopy findings were all documented. The incidence of HP was calculated and compared with the quoted incidence in the literature. Outcomes. Five women with HP presented to the EPU over the course of a year. The first case describes a spontaneous HP with a previous salpingostomy. The second case describes an HP following ovulation induction. The third case describes a spontaneous HP with no known risk factors. The fourth and fifth cases describe heterotopic pregnancies following in vitro fertilisation with more than one embryo. All five cases of HP underwent laparoscopy and salpingectomy with uneventful recovery. The three women who had a viable IUP had no further complications in their pregnancies.

Conclusion: Early and accurate diagnosis of HP can be challenging. An early transvaginal ultrasound plays an important role in making the diagnosis in women with risk factors and following ART. A high index of suspicion is required for timely diagnosis and appropriate intervention, especially in spontaneous HP.

Background: Cervical pregnancy, an uncommon type of ectopic pregnancy, can lead to devastating consequences if not diagnosed and treated early. Despite this, there are no specific guidelines on how to treat such pregnancies especially in advanced gestational ages (GAs).

Case: This is a 35-year-old patient who presented to our hospital at 13 weeks GA after failing systemic multidose methotrexate therapy for a cervical ectopic pregnancy. Given desire to preserve fertility, a minimally invasive conservative approach was taken involving potassium chloride (KCl) and methotrexate injections into the gestational sac, followed by immediate Cook intracervical double balloon placement under direct ultrasound visualization, with removal of the balloon after 72 hours, and ultimately resolution of the pregnancy 12 weeks after the removal.

Conclusion: Advanced first trimester cervical ectopic pregnancy after failure of methotrexate therapy was managed successfully with minimally invasive KCl and methotrexate injections in combination with cervical ripening balloon.

Background: Persistent elevation in beta-human chorionic gonadotropin (β-hCG) following a pregnancy is concerning for gestational trophoblastic neoplasia (GTN). However, the differential diagnosis should remain broad during the evaluation process.

Case: A 34-year-old G3P3 presented with elevated β-hCG four months after cesarean delivery with bilateral tubal ligation. The patient was treated with methotrexate for a presumed new ectopic pregnancy. Due to persistent β-hCG elevation, she received actinomycin-D for GTN treatment. After completing chemotherapy, her β-hCG increased. The patient underwent a laparoscopic hysterectomy with unplanned left oophorectomy due to its nodular appearance at the time of surgery. Pathology confirmed a dysgerminoma of the ovary and benign uterus.

Conclusion: Although dysgerminomas are uncommon, they should be considered when β-hCG levels remain elevated despite therapies for more common pathologies.

Human myiasis is an infestation produced by fly larvae invading the tissues. We present a case of a 40-year-old virgin woman with vulvar myiasis. She reported at the gynecology clinic with a bloody discharge, severe pain, and swelling of the genital area for six days. Her menstrual history revealed the use of folded clothes. She had no specific gynecological disease. At the examination of the external genitalia, a tender mass measuring 6 cm × 4 cm and an ulcer measuring 1 cm × 1 cm on the surface of the labia majora were found. The patient was hospitalized. Serology, blood, and urine tests were requested; all laboratory tests were normal. The patient was transferred to the operating room (OR) with the diagnosis of necrotizing fasciitis. In the OR, we performed a longitudinal incision on the mass and removed nearly 30 visible maggots. After washing with normal saline, the patient was transferred to the ward without wound suturing. Debridement of the necrotic vulvar mass along with daily washing was performed for 7 days. The wound was sutured on the seventh day at the OR. Antibiotic therapy was continued for 4 days, and the patient was discharged with normal laboratory tests on the eleventh day after admission. We believe that poor sanitary hygiene was the cause of vulvar myiasis in our patient. We conclude that appropriate measures must be taken to reduce the risk of human myiasis, especially in tropical rural regions.

Hydatidiform mole, complete or partial (CHM/PHM), is the most common type of gestational trophoblastic disease (GTD), which is characterized by excessive trophoblastic proliferation and abnormal embryonic development. Some patients present with sporadic or familiar recurrent hydatidiform moles (RHMs), which are characterized by two or more episodes of the disease. A healthy 36-year-old woman was admitted to the Obstetrics and Gynecology Unit of Santa Maria Goretti Hospital, Latina, because of RHMs at 6 weeks of amenorrhea, with an obstetrical anamnesis of RHMs. We performed uterine dilatation and curettage with suction evacuation. The histological examination confirmed the diagnosis of PHM. The clinical follow-up was conducted according to recent guidelines on the diagnosis and management of GTD. After the return to the baseline values of the beta-human chorionic gonadotropin hormone, a combined oral contraceptive therapy was proposed, and the patient was invited to undergo in vitro fertilization (IVF) techniques, specifically oocyte donation, to reduce the possibility of similar future cases of RHMs. Although some etiopathogenetic mechanisms involved in RHMs are still unknown, all patients of childbearing age who are affected by this syndrome should be properly treated and directed towards a correct clinical path as IVF, to have a successful and safe pregnancy.

Twin reversed arterial perfusion (TRAP) sequence or acardiac twin is a rare and severe complication of monochorionic multiple pregnancies. Acardiac twin accounts for 10% of all TRAP sequences, which is the most morphologically developed acardius. We present an undiagnosed TRAP sequence case up to 24 weeks of gestation who underwent successful amnioreduction, radiofrequency ablation (RFA), and intrauterine transfusion (IUT). During follow-up, hydrops of surviving co-twin disappeared, and fetal heart function improved. Finally, a healthy girl weighing 2400 g was born at 36 weeks of gestation. To our knowledge, this is the first reported acardiac twin pregnancy, which requires IUT, in addition to RFA, due to late diagnosis. Therefore, this case report presents successful management options for TRAP sequence cases diagnosed late in pregnancy.